Kapok: In praise of the vouchers

Let me be honest: at first I was more than doubtful about what I was reading, and one could even say that I started looking deeper into the matter with pretty self-assured and somehow offensive ulterior motives. Come on, how could this be? “A study concludes that healthcare vouchers have prevented 123 deaths a year,” read a headline, or in this very newspaper, a milder “Study: Medical Vouchers Prevented Fatalities, Should be Given to TNRs.” For those of you not aware of cross-feeding multilingual acronyms, “TNRs” means non-resident workers, as in the very elegant perfunctory statistical category derived from the Portuguese “trabalhadores não residentes”. So vouchers distributed by the government equal saving lives, and this should be indiscriminate when it comes to human life, hence the noble appeal to extend it to all the contributing participants to and of the community. When absolute efficiency meets generosity…
A scientific mind has a craving for heuristic (meaning that one is always trying to find causality) relations: what are the causes behind a phenomenon, and to what extent these causes alone can explain things. In social sciences, the real “hard sciences” as everything is more complex when one deals with human nature, single factor explanations are pretty rare to come by, and often follow rather cryptic statistical considerations in which the whole exercise consists in isolating factors and relating a dependent variable (in this case mortality because of a disease) with an independent one (the introduction of vouchers).
The press reports based on a Lusa dispatch insist on the main conclusion of Professor Zhang Jinghua’s study, that a 24 percent decrease in cardiovascular diseases recorded as of 2010, compared to the 2001-2009 period, can be directly connected to the introduction of medical vouchers back in 2009, resulting in the prevention of 123 deaths a year over 2010-2012 (the claimed drop in mortality, 0.22%, multiplied by an average of 560,000 residents over the period). And vouchers are here seen as having a direct influence on citizens scheduling health checks or taking medical exams that would have otherwise probably not been undertaken without this exclusive incentive.
My first reaction was not to go to the report but to international studies, especially one by the OECD that indicates that the main reasons behind the sharp decrease in cardiovascular disease mortality rates have to do foremost with the decline of tobacco consumption and also with the improvements in medical care—why would Macao be any different? Then, I went to the official statistics, and if it indeed shows a decline in mortality rates for “cardiovascular diseases” in recent years, it also indicates that the year with the least number of deaths because of cardiovascular issues was in 2007 and the mortality rate because of respiratory diseases has increased rather significantly—the number of deaths because of respiratory diseases used to be 1/3 of the one for cardiovascular diseases, now it is 2/3!
So I finally went directly to the source, and Professor Zhang’s study is indeed pretty comprehensive and compelling, taking into account a multiplicity of factors (medical resources—numbers of physicians, nurses and patient beds per thousand population and public healthcare expenditure, economic development level—GDP per capita, the human development index, population ageing factor, natural seasonal effects and long-term trends), scrutinising the yearly reports of the Macao Health Bureau (incidentally pointing out to the inefficiency of the awareness and educational campaigns) and even admitting to certain shortcomings in the lack of compelling statistics about cerebrovascular diseases or simply the rather limited consideration given to the improvement of medical care because of new technologies, better training and more efficient drug therapies. Ultimately, in its own words, the study merely “suggests a robust connection between the timing of the implementation of the Macao Medical Voucher Program and a significant decrease in the mortality from circulatory system diseases in Macao, but their causal relationship awaits confirmation in further research.” The mere fact that the cancer mortality rate has increased significantly over the same period—as indicated in the study—should have led to more caution in the media reports: I would bet my salary that the vouchers program, conversely, was not responsible for that!


Published in Macau Daily Times, September 19th 2014

Kapok: Hong Kong and us

The recent debate over universal suffrage for the 2017 election of the Chief Executive in Hong Kong, and the much anticipated ruling made by the National People’s Congress (NPC) last Sunday over the issue have proven both fascinating and, rather unfortunately, extremely worrying.
Fascinating because the political awareness demonstrated by the Hong Kong citizenry at large has become a key feature of the distinct identity of our sister SAR. This was not originally “a given”, and it became salient only back in 2002-2003 over the debate regarding article 23 and the appending national security law with the SARS outbreak as a backdrop. Social movements and unrests of some significance have quite a long history in Hong Kong, but then the triggering causes clearly used to intertwine anti-colonial sentiments and mainly labor issues with China’s own turmoil of the time, as exemplified by the massive riots of the 1920s and 1960s. The vast demonstrations in the wake of the Tiananmen massacre in June 1989 were already encompassing a wider array of the population, but the scale of the mobilization was commensurate with the emotional shock felt by many because of the blood-stained character of the repression, and then genuine feelings of solidarity with the victims precipitated growing fears about the future of Hong Kong itself after 1997. The 2003 events mark a turning point as they took place after the handover to Chinese sovereignty and mainly gathered white-collar and professional segments of society, along with their families, and thus exhume the coming of age of what political scientists characterize as a “vibrant civil society”, targeting the government for being too weak in its commitment to uphold “a high degree of autonomy” for the SAR. Since then, the “civility” of society has grown both in strength and scope, whether one considers attendance to the June 4th vigil in Victoria Park, the youth-led Scholarism movement against patriotic education, the Occupy Central movement and of course the civil referendum of June 2014.
The worrying side derives palpably from the inflexible stance adopted by the central authorities, as the NPC ruling completely excludes popular initiatives by requiring candidates for the 2017 elections to be endorsed by a majority vote casts in a non-elected 1,200-member nominating committee, and furthermore limits the number of candidates to two or three nominees. Quite a stark contrast with the winning motion of the civil referendum that garnered the acquiescence of more than 330,000 people for a “three-track” proposal (public, nominating committee and parties) to put forward candidates! For Michael Davis, professor of law at the University of Hong Kong, this constitutes a major betrayal of the spirit and letter of both the 1984 Sino-British Joint Declaration and the Hong Kong Basic Law as it subverts completely the commitment to universal suffrage. In a very strong opinion published in the South China Morning Post on September 3rd, Prof. Davis further argues that not only does this ruling undermine the rule of law, but also infringes international law as it contradicts the International Covenant on Civil and Political Rights, of which Hong Kong is a signatory—article 25 of that Covenant provides every citizen the right “to vote and to be elected at genuine periodic elections which shall be by universal and equal suffrage… guaranteeing the free expression of the will of the electors—, and furthermore contradicts the aim, as voiced out by Deng Xiaoping himself, for Hong Kong people to “put their hearts at ease”. For all these reasons, Prof. Davis concludes—without any risk of being sacked—that “democrats in the Legislative Council have no reason to support a bill under these constraints”.
What is there for us when Article 47 of our Macao Basic Law unmistakably lacks a straightforward commitment to universal suffrage? Well, first, this acts as a reminder that Macao is also a signatory of the International Covenant on Civil and Political Rights [see art. 40 in the 3rd section of the MBL], and thus, if we follow the UN Human Rights Committee that interpret the Covenant, that not only suffrage should be “universal and equal” but that “persons entitled to vote have a free choice of candidates”. And then, we have the statement of Li Fei, the deputy secretary general of the standing committee of the NPC sent to Hong Kong to explain the ruling: “Only one person [candidate] does not make an election, but too many is not proper either” [一個人就不是選舉，但多了也不合適]. This constitutes a prompt recall that elections are chiefly about building trust, and thus Mr Chui’s commitment to further develop democracy in Macao, as stated in his 2014 platform, appears more pressing than one would have initially expected.

Published in Macau Daily Times, September 5th 2014